hind-quarter amputation - postgraduate medical journal · hind-quarter amputation by l. p. le...

September 1949 LE QUESNE : Hind-Quarter Amputation 433

A tendency to use thick catgut at operation isdue to an unfounded fear that fine stitches may beinsufficiently strong to hold the wound edges inapposition, Great force is not normally necessaryto keep a wound closed and even if considerablestrain is expected, as in retching or coughing afterlaparotomy, it is more likely that the sutures wouldcut out of the tissues than that the stitches them-selves would break.,The shearing strain of tissues, which is

analogous to their resistance to the cutting out ofstitches, is not so high as appears to be generallybelieved, varying from less than I lb. in softtissue, as for instance bowel, to no more than 24lb. in rectus muscle sheath. The minimumstandard breaking strain for No. 2/0 catgut, evenwhen knotted, is 3 lb. This bears out the ex-periments of various workers who advocate the useof fiher catgut sutures than those commonly used,with No. o for fascia as the thickest recommended,down to No. 3/0 or No. 4/0 for muscle, peritoneumand subcutaneous tissue (Howes, I929, I941).

Suspected infection in a wound need not be areason for using thick catgut; besides the additionof 'thick catgut reaction' to the bacterial dis-turbance, it is by no means certain that a moderateinfection speeds up the absorption of catgut ex-cessively. In a summary of a large number ofabdominal wound disruptions, it was found thatthe cases in which infection was present disruptedconsiderably later than the clean cases.

Furthermore, with the considerable improve-

ments in the manufacture of surgical catgut overrecent years resulting in greater tensile strength,there is no justification on this score for using thethicker sizes.

ConclusionTo summarize the points covered in this general

survey of catgut as a suture material :I. The fundamental advantage of catgut is its

absorbability.2. It has excellent tensile strength.3. Sterility, as taken from the sealed tubes, is

assured.4. A hardened or 'chromed,' catgut is pre-

ferable to the ' plain' variety.5. The finest possible sizes should be used in

preference to thicker sizes.In conclusion, the following quotation from

Mikulicz is offered with respect and sincerity:-'Je reconnais le bon chirurgien, non pas a la

fafon dont il coupe, mais a la faFon dont il saitrecoudre.'

BIBLIOGRAPHY

FANDRE, A. (i944), 'Le Catgut,' Masson et Cie, Paris.WILLIAMS, F. E. (1936), 'Alcohol and Sporing Organisms,'

Med. Jour. Australia.HOLDER, E. J. (I939), ' Surgical Sutures and Ligatures,' E. & S.

Livingstone, Edinburgh.HOLDER, E. J. (1946), 'Desirable Factors in Surgical Sutures,'

Wm. Blackwood & Sons, Ltd., Edinburgh.JENKINS, H. P., et al. (1942), Arch. Surg., 44, 88I, 984.JENKINS, H. P., et al. (1942), Ibid., 45, 74.JENKINS, H. P., et al. (1942), Ibid., 45, 323.HOWES, E. L., and HARVEY, S. C. (I929), New Eng. J. Med.,

200, I285.HOWES, E. L. ( 4x), Surg. Gyn. and Obst., 73, 319.

HIND-QUARTER AMPUTATIONBy L. P. LE QUESNE, M.A., F.R.C.S.

Second Assistant, Surgical Professorial Unit, Middlesex Hospital

Hind-quarter amputation was first performed ini891 by Billroth (1902), but it was not until i895that a successful result was obtained by Girard(I895). Since that time the operation has beenperformed by many surgeons with increasingsuccess. Pack and Ehrlich (1946) report that 132cases are recorded in surgical literature over thelast 50 years. Sir Gordon Gordon-Taylor, in I946,reported a personal series of 2I cases, and sincethat time has performed a further i i such opera-tions ; it is largely as a result of his work that thisformidable ablation has been established in thiscountry as a standard procedure in the surgicalmanagement of malignant disease.

In most cases the operation is performed forprimary malignant tumours of the bones or con-nective tissues of the pelvis, or for similar tumoursin the upper third of the thigh which have ex-'tended too far proximally to allow of disarticula-tion through the hip-joint; typical of the tumoursnecessitating this procedure are those illustrated inFigs. I and 2. On occasion the operation has beenperformed for extensive tuberculous or chronicinflammatory disease. of the hip and pelvic bones.By virtue of their less sinister pathologicalpotentialities, the best results are obtained in caseswhere the tumour is .essentially only of localmalignancy, such as infiltrating chondromas of the

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434 POST GRADUATE MEDICAL JOURNAL September 1949

ilium and giant neurofibromas of the sacral plexus;but brilliant results have been obtained in thetreatment of grossly malignant tumours, and thepurely palliative relief given in many cases is ofconsiderable value. Whilst there can be no doubtthat the operation is one of the most formidablein surgery, it is also certain that in properlyselected and handled cases it can give results morethan commensurate with the risks and anxietiesincurred.

Pre-Operative PreparationAny significant degree of anaemia is, of course,

corrected before operation and the general stateof the patient's health is carefully assessed. Some24 hours before operation courses of penicillin anda suitable sulphonamide are started as a prophy-lactic measure. Immediately before operation anintravenous drip should be set up and a gum-elastic urethral catheter tied in ; to avoid dis-turbing the patient these two procedures arecarried out after anaesthesia has been induced.Owing to the likely need for rapid massive trans-fusion it is advisable to set up two intravenousdrips. In most cases these are both inserted in theforearm of the side not involved in the operation,in which position they are readily accessible andcan be controlled by one person without impedingthe operating team.Once the patient has been put in position on the

table, with drips and catheter in place, two finalpreparations remain to be done, the application ofan Esmarch bandage as an exsanguinating tourni-quet from toes to mid-thigh, and the stitching inplace of a veil of oiled silk to cover over and isolatethe anus. This veil is stitched close to the anus toavoid encroaching on the operative field.

Anaesthesia and Control of TransfusionThe usual pre-operative injection of omnopon

and scopolamine is given one hour before opera-tion. Many forms of anaesthetic would servesatisfactorily for this operation, but the followingtechnique has given excellent results in severalcases and seems to fulfil most requirements.Anaesthesia is induced with pentothal, followingwhich a nasal endotracheal tube is passed, afterpreliminary spraying of the larynx with cocaine;anaesthesia is then maintained with nitrous oxideand ether administered through the tube. Afterplacing the patient on the operating table aunilateral spinal block is given, using io ml. ofI/I,500 light nupercaine. With this technique allpainful stimuli are interrupted and only a lightplane of general anaesthesia need be maintained.Once the operation has begun a blood trans-

fusion should be started at such a rate that mostof the first pint has been administered at the com-

pletion of the anterior dissection. During theposterior dissection, especially if sacro-iliac dis-articulation is performed, shock is likely to bemore marked, and is often exacerbated by haemor-rhage from the gluteal region. Accordingly dur-ing this time rapid transfusion is required, and it isnow that two drips may prove their value (Figs.3 and 4). Usually 3 or 4 pints of blood are re-quired during and immediately after the operation,and a further I pint administered some 6 to 7hours post-operatively is often valuable. In somecases however considerably greater quantities ofblood may be required, and 8 to io pints should beready cross-grouped before operation.

II

V vSYSTOLIC

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so

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(IIME IN HOURS

FIG. 3.-Graph showing blood pressure and pulseduring an uncomplicated hind-quarter amputation.Compare with Fig. 4.

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40

lb 1 61 2 4 8 4tia IN HOURS

FIG. 4.-Similar graph to Fig. 3, showing the seriousdegree of shock associated with sacro-iliac dis-articulation. Note the improvement consequentupon rapid, massive transfusion. (Figs. 3 and 4are reproduced by kind permission of Dr. BrianSellick, who gave the anaesthetic in these two cases.)



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September I949 LE QUESNE : Hind-Quarter Amputation 435

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FIG. I.-A typical case requiring hind-quarter amputa-tion. This man had an infiltrating chondrosarcomaof the ilium, extending so far back that sacro-iliacdisarticulation was necessary. The scar of anattempted previous local excision is visible.

Position on the TableThe patient is placed lying on his sound side

but tilted slightly towards the surgeon who standsbehind the patient. One sandbag is placed in thesmall of the back and another behind the soundthigh. The upper arm is fixed on an arm rest asfor nephrectomy, whilst the lower is held out on aboard. The leg to be amputated is held by anassistant; the other two assistants stand oneopposite the surgeon and the other by his side.

OperationThe incision employed is a modification of that

designed by Girard (Fig. 5). Starting at theposterior superior iliac spine it runs forwards ½to I in. above the iliac crest, and continues downabove the inguinal ligament until just short ofthe pubic spine, where it is carried down acrossthe adductor origins. Posteriorly the incisionruns from the posterior superior spine to theischial tuberosity and thence follows the glutealfold to join the anterior portion. Only the an-texior portion of the incision is made at first ; inthe legion of the iliac crest this incision is im-mediately deepened through all layers of theabdominal wall to enter the extraperitoneal spaceover a distance of 3 to 4 in. A band is then in-serted, and the peritoneum swept off the lateral

wall of the pelvis as far forwards and downwardsas possible (Fig. 6). This most important stepenables the surgeon to explore the internal extentof the tumour and to gauge its invasion of theperitoneum at an early stage of the operation. Ifthe tumour appears irremovable, the operation canbe abandoned before important vessels have beenligated.The division of the flat muscles of the abdominal

wall is then continued down to the pubis, the cordbeing carefully swept medially and upwards withthe peritoneum. This line of division may pass2 in. above Poupart's ligament, running throughthe muscular internal ring and across the posteriorwall of the inguinal canal, or the inguinal ligamentmay be detached from bone at both ends and leftattached to the abdominal musculature. In eithercase the deep epigastric artery must be securedand divided (Fig. 7). The bladder is thenseparated from the back of the pubis and fromthe rectus muscle, which is divided at its attach-ment to the pubis (Fig. 8).The peritoneum is now stripped widely from

the lateral pelvic wall, and the ureter, which re-mains with the peritoneum, is carefully identifiedand preserved. The external iliac artery and veinare dissected out and divided between heavysilk ligatures, followed by ligation in continuity ofthe internal iliac vein and the posterior divisionof the internal iliac artery (Fig. 9). If isolation ofthis latter vessel is difficult, it is permissible toligate the incernal iliac artery itself, but preserva-tion of its anterior division is to be preferred.After division of these vessels the obturator nerveis identified and divided. The anterior part of thedissection is then completed by division of thepsoas muscle, the upper part of the origin of theiliacus, the femoral nerve and the lateral cutaneousnerve of the thigh. The inner aspect of the sacro-sciatic notch is now visible (Fig. Io).

For the posterior dissection the patient isrolled gently away from the surgeon and, after theincision has been made, the flap is dissected upmedially and posteriorly. The gluteus maximusis preferably included in the flap, but in some casesthe extent of the tumour may not permit this(Fig. ii). A little dissection will now expose theposterior aspect of the sacro-sciatic notch, andafter division of the origin of the glutei, a Gigli sawcan be passed through the notch and the wing ofthe ilium divided outwards and backwards. Thesaw is best inserted by passing the points of aMoynihan's forceps through the notch fromwithin the pelvis and then withdrawing the wire intheir teeth. After division of the ilium, the boneshould be retracted laterally and the pubic sym-physis divided; this can often be done with aknife but a chisel may be necessary, and in any



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FIG. 2.-Two views of a specimen removed by hind-quarter amputation. This man hada reticulum-cell sarcoma of the inguinal lymph glands, which had recurred after heavyirradiation. The tumour was infiltrating the ilium and ulcerating through the skin.



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September I949 IE QUESNE : Hind-Quarter Amputation 437

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FIG. 5a.-Diagram illustrating the incision used forhind-quarter amputation. In certain casesmodifications may be required to secure adequateflaps.

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AFIG. 5b.-Diagram to show the lines of bone section.

The shaded area shows the amount of bone normallyexcised, though on occasion sacro-iliac disarticula-tion may be required, as shown by the dotted line.

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FIG. 6.-The incision parallel to the iliac crest has beendeepened through the muscles, and a hand is in-serted to explore the inward, pelvic extent of thetumour.



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FIG. 7.-The ligation of the inferiorepigastric vessels. The spermaticcord has been mobilized and re-tracted well medially.

case the division is made easier by lateral re-traction of the pelvis.

Completion of these two' bcne sections nowallows the half pelvis to be drawn and rotatedlaterally, and in this position the crus penisshould be detached from the pubic ramus, theknife being kept close to the bone throughout(Fig. 12). Turning now to the inner aspect of thepubis, the thick, anterior, pubo-rectalis portionof the levator ani should be identified; bothsurfaces of the entire levator can then be cleared

and divided from before backwards (Fig. 13),care being taken to retract the rectum medially.It now remains only to turn the pelvis forwardsagain and divide the piri-formis muscle, thesciatic nerve, the sacro-tuberous and sacro-spinous ligaments and the limb will be free, thenerve and muscle being cut as they leave thepelvis, and the two ligaments close to the tuberosityand spine respectively. During this last stageof the amputation the various smaller nerves andvessels leaving the pelvis through the sacro-sciatic

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........................FIG. 8.-With a hand inserted to retractand shield the bladder and peri-toneum, the rectus muscle is detachedfrom the pubis.



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September I949 LE QUESNE : Hind-Quarter Amputation 439

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notch are divided, but time is not wasted inidentifying them.

Following removal of the limb careful attentionis given to haemostasis, and after dusting withpenicillin powder the wound is closed. Thisclosure can usually be done in two layers, firstmuscle then skin; a large corrugated drain,passed deep to the muscles, is brought out pos-teriorly. The dressings should be firmly strappedin position with long lengths of broad elasto-plast.

ModificationsThe procedure described is not applicable to all

cases, because in some the tumour extends sofar proximally that division through the sacro-sciatic notch is not practicable. In such casesthere remains the alternative procedure of sacro-iliac disarticulation (Fig. 5b). There can be nodoubt that this materially increases the severity ofthe operation. It is unnecessary foi all cases but isinvaluable in some. The disarticulation is per-formed most easily from the front, after careful

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FIG. Io.-The anterior dis-section has been completedby section of the psoas andiliacus muscles, betweenwhich two structures canbe seen the divided femoralnerve. Forceps have beeninserted into the sacro-sciatic notch, at the site ofbone section.



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440 POST GRADUATE MEDICAL JOURNAL September I949

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FIG. I I.-The posterior incision hasbeen deepened through the glu-teus maximus, to expose theposterior aspect of the sacro-sciatic notch. The dotted lineindicates the line of division ofthe ilium.

retraction of the iliac vessels from the surface ofthe joint. When the joint space has been identifieda chisel is used to separate the two bones, and inusing this instrument it is essential to rememberthat the joint lies obliquely, and that the chiselmust be directed backwards and inwards towardsthe midline. Apart from this one major variant,there are many miner alterations in incision andprocedure which may be necessary in certain casesbut do not 'essentially alter the operation.Post-Operative CareOn return to the ward the Fatient is placed on a

water bed, with the foot raised on blocks and a

sandbag against the sound hip. The blocks areremoved and the drip regulated according to thestate of the patient, usually both being dispensedwith by the morning after operation. Thecatheter should be connected to a Duke's or tidaldrainage apparatus, and can be removed on thethird to fourth post-operative day when normalmicturition usually returns..The first dressing, preferably under light

anaesthesia, is done on the third or fourth daywhen the drain is removed; thereafter thedressing is changed as necessary. The skinsutures should not be removed hastily, as the flapstake time to unite firmly and some sloughing of

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Fic. 12.-A diagram to show the cruspenis being cut off the pubic ramus,after both bone sections have beenmade and the half-pelvis retractedlaterally and backwards.



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September 1949 LE QUESNE : Hind-Quarter Amputation 44I

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"iG. I3.-The levator ani is divided from before back-wards, its anterior, pubo-rectalis portion beingthick and muscular. During this procedure therectum, bladder, prostate, and peritoneum must beprotected from injury. The sciatic nerve can beclearly seen running across the face of the piri-formis muscle: the ureter, vas and cord are alsoshown, in contact with the peritoneum.

the posterior flap may occur. Removal shouldnot be begun before ten days and some stitchesmay well be left for 15 days.

Whilst the patient is confined to bed carefulattention is paid to the pressure points, the patientbeing rolled to either side for attention to hisback ; nor should the remaining heel be over-looked. Usually the patient gets up on the seventhpost-operative day, and as strength returns can betaught to use crutches.

During the first two to three weeks after opera-tion a close watch is kept on the haemoglobinlevel, and it may well be necessary to give afurther transfusion some ten days after the opera-tion. During this period the patient often be-comes generally depressed and exhausted as aresult of the strain of the operation and a fullrealization of the extent of the ablation, andapart from physical measures encouragement andsympathy from surgeon and sisters are of para-mount importance.Discussion

Fortunately the circumstances requiring per-formance of a hind-quarter amputation are notcommon. Equally fortunately, coincident withthe operation being put on a sound anatomical andsurgical basis, modern developments have largely

diminished the two great problems associated withit in the past-the immediate risk to the patientowing to the magnitude of the operation and thesubsequent disability following so extensive anablation.

In I935 Gordon-Taylor and Wiles (I935) foundthat the mortality rate in 55 cases collected fromthe literature was 56.4 per cent., but by I946Gordon-Taylor and Patey (I946) were able to re-port 8o cases from various sources with a recoveryrate of 82 per cent., and on a personal series of2I cases with 71 per cent. recovery. SimilarlyPack and Ehrlich (I946) report that ' during thepast quarter of a century the operative mortalityhas been gradually lowered from 50 per cent. toabout 5 per cent.,' and go on to record a personalseries of six cases involving sacro-iliac disarticula-

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FIGS. 14 and 15.--V.P., 2z years after left hind-quarteramputation; he is wearing the special prosthesisreferred to in the text. Note the compensatoryscoliosis, which frequently develops. (These twophotographs are reproduced by kind permissionof the Director of Medical Services, RoehamptonHospital, and of Mr. Ivor Lewis, F.R.C.S.)



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442 POST GRADUATE MEDICAL JOURNAL September I949......::

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tion without a death. Sir Gordon Gordon-Taylor's personal series now amounts to 32 cases,with eight deaths ; during the past few months,of the four hind-quarter amputations performedon this unit only one has given rise to undueanxiety, and he ultimately died on the I6th post-operative day.

Involving as it does section of considerablemuscle masses, division of bone, often heavy re-traction and, on occasions, severe haemorrhage,the operation is inevitably associated with a con-siderable degree of shock, and to undertake itwithout adequate preparations for extensive andrapid transfusion is to court disaster. However,unlike many patients with extensive growthspresenting themselves for operation, patients re-quiring hind-quarter amputation are usually infair general condition and do not exhibit grosssystemic and nutritional disorders. Furthermore,the problem presented is the straightforward acuteone of combating shock and haemorrhage, un-accompanied by the immediate and remote com-plications of radical operations involving extensive

resections of abdominal or thoracic viscera. Withthe better understanding of the value of adequatetransfusion in the treatment of shock, this problemhas been at least partly solved with a consequentsubstantial reduction in the mortality (Figs. 3and 4).

Until recently, after this operation patients werecompelled for the rest of their lives to rely oncrutches for getting about, and in spite of theassurance and agility that many developed thedisability was severe. Within recent years, how-ever, there has been developed at Roehampton aprosthesis which enables these cases to walk well.The leg is secured by abdominal straps and noshoulder band is required (Figs. I4, 15, i6).Though patients wearing this limb have a pro-nounced limp, its development has been of greatvalue in improving both their appearance andtheir self-reliance. A stick is usually necessary.There can be no doubt that the modern de-

velopments in blood transfusion and limb-makingdiscussed above have materially diminished thehazards and drawbacks to the hind-quarteramputation. It nevertheless remains a formidableprocedure, and its successful performance de-pends upon team work. Throughout the whole ofthe pre-operative treatment, operation and post-operative period, close co-operation between thesurgeon, his assistants and the nursing staff isessential. If severe haemorrhage occurs duringthe operation it may well need all the efforts ofsurgeon, anaesthetist and transfusion officer to seethe patient safely through, whilst during the post.operative phase it is only by unremitting attentionto detail that success can be attained.

It is impossible to give adequate expression ofmy thanks to Sir Gordon Gordon-Taylor for hisadvice, encouragement and constant assistance inthe preparation of this article, and further for theaccess he has allowed me to the records andpictures of his cases. My thanks are also due toMrs. C. G. Trew and the staff of the Photo-graphic Department of the Middlesex Hospital fortheir skill and care in the preparation of theillustrations, as also to Mr. R. S. Monro andothers who assisted me in the necessary dissections.

BIBLIOGRAPHY

BILLROTH, T., quoted by SAVARIAUD, W. (1902), Rev. Chir.Par., 26, 350.

GIRARD, C. (I895), Congrds Franc. de Chir., 9, 823.GORDON-TAYLOR, G., and WILES, P. (x935), Brit. J. Surg.,

22, 671.GORDON-TAYLOR, G., and PATEY, D. H. (I946), Brit. J.

Surg., 34, 6i.PACK, T. G., and EHRLICH, H. E. (1946), Ann. Surg., 24, 1.



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